What You Need to Know about Enhanced Recovery and Outpatient Surgery

Posted on February 22, 2017

Ambulatory surgery centers are all about finding and pioneering new, more effective ways of efficiently delivering high quality care. So it’s hardly surprising to find that ASCs and outpatient centers across the US are embracing what’s known as “enhanced recovery,” a new approach to surgery that is transforming the surgical experience for patients and providers alike. Read on to learn more about what enhanced recovery is, and why it’s such a good fit for an outpatient setting.

What is enhanced recovery?

Also known as “enhanced recovery after surgery (ERAS)” or “enhanced recovery pathways (ERP),” the term “enhanced recovery” describes a multi-modal, integrated care pathway that is designed to reduce patient stress in response to surgery and help patients return to normal daily functioning as soon as possible. In other words, enhanced recovery is essentially a new set of recommendations and practices that guide patients and surgeons before, during, and after the surgical procedure. The overall goal of these protocols is to minimize the disruption of the patient’s normal physiology as much as possible.

Henrik Kehlet, a Danish professor of surgery, initially pioneered the concept of enhanced recovery in the early 1990s. Since that time, the use of enhanced recovery protocols has gradually become more widespread, primarily in Europe and North America.

How does enhanced recovery differ from traditional surgical protocols?

The primary focus of traditional surgical care principles—like prolonged fasting, periods of mandatory bed rest, and the use of general anesthesia—is to ensure that the surgical procedure goes as smoothly as possible, with less concern placed on how those care principles and techniques might affect the patient. But enhanced recovery adopts a “patient first” approach, recognizing that major surgery is hugely stressful for the human body and seeking ways to mitigate that stress without compromising the quality of the surgical procedure. Some of the areas where traditional and enhanced recovery approaches differ include:

Fluid consumption before surgery—The rule for traditional surgery has long been that the patient should have nothing to eat or drink for at least 12 hours prior to surgery, thus essentially putting the body into “starvation mode.” The enhanced recovery approach, while still having patients abstain from eating for the same length of time, allows liquids to be consumed until just two hours before surgery, with a particular focus on clear fluids with plenty of carbohydrates, like Gatorade. This helps fuel the body up before undergoing the surgical procedure, and prevents acids from building up in the stomach during fasting.

Fluid use during surgery—Because patients following an enhanced recovery protocol are better hydrated at the beginning of surgery, not as much fluid needs to be introduced into the body (via IV drips, for example) as it does in traditional surgery. This helps reduce bloating in patients during recovery, and minimizes stress on the heart and the chance of wounds becoming infected.

Use of anesthesia—General anesthesia, which puts the entire body to sleep, was once used for virtually all surgical procedures. Now, unless the procedure is highly invasive, regional blocks, also known as local anesthesia, are used instead, thus minimizing the effect on the patient’s system and allowing for a quicker recovery.

Use of narcotics—One of the biggest differences between traditional and enhanced recovery approaches concerns what medications are used to manage pain. Opioids or narcotics like morphine are frequently used in traditional surgery, but they come with many adverse side effects, such as nausea or vomiting, feelings of delirium, and the possibility of addiction. Now, pain is attacked differently, often through a combination of anti-inflammatories, Tylenol, and steroids, which help manage pain while minimizing other undesirable side effects.

Post-operative mobilization—Unlike the prolonged periods of bed rest that characterize recovery after traditional surgery, enhanced recovery approaches have patients getting mobile as early as possible following the procedure. This helps encourage the body to return to normal functioning, and is possible because of the lack of grogginess from narcotics.

Post-operative nutrition—Again, because enhanced recovery patients are not taking the opioids that lead to nausea and vomiting, they are typically able to begin eating more quickly after surgery, helping to fuel the body and stimulate the digestive system.

Why is enhanced recovery a good fit for ASCs?

The principles of the enhanced recovery approach align well with some of the main goals of ASCs: delivering efficient care, improving patient satisfaction, minimizing complications, and controlling costs. Because enhanced recovery patients have a faster recovery time than traditional surgery patients, their facility stay is much shorter. A 2015 UVA Medical Center study on enhanced recovery patients undergoing colorectal surgery found that the length of their hospital stay dropped to an average of 4.5 days from the 6.9-day average for patients who were not treated through enhanced recovery protocols. The ability to decrease the length of stay and make it easier for patients to return home sooner is ideal for the outpatient setting that ASCs provide, which are already focused on minimizing time in the facility and facilitating better care and recovery for patients at home.

In addition, ASCs can benefit from the potential that enhanced recovery has shown in reducing post-operative complications. The UVA Medical Center study found that enhanced recovery led to a drop in the surgical complication rate from 30% to 15%, and in the 30-day readmission rate from 19% to 7%. Reducing complications and readmissions is an important strategy in helping care facilities control their costs.

Finally, shorter stays, an earlier return to normal functioning, and a more integrated post-operative care approach all help improve the patient experience, and are thus instrumental in boosting patient satisfaction rates, both at inpatient and outpatient facilities.